EX-99.(5)(A) 4 ex995a.htm INDIVIDUAL APPLICATION FORM ex995a.htm
 
First Security Benefit Life Insurance
and Annuity Company of New York
SecureDesigns® Variable Annuity Application 
     
First Security Benefit Life Insurance and Annuity Company of New York (“FSBL”). Questions? Call our Customer Service Center at 1-800-888-2461.
 
 
Instructions
  
 
Complete the entire form to establish a new SecureDesigns® Variable Annuity Contract. Please type or print.
 
 
1. Choose Type of Annuity Contract
  
 
Please select the annuity type:                  m Non-Qualified                   m 403(b) TSA                 m Traditional IRA                    m Roth IRA
  Initial Contribution $
 
  
 
For IRAs only: Current Year $
  
Prior Year $
 
  
Rollover $
 
    
                   
 
2. Provide Annuitant Information
  
Name of Annuitant
 
  
 
      
m Male      m Female
 
First
  
MI
  
Last
    
Mailing Address
                
 
Street Address
  
City
  
State
  
ZIP Code
  
Residential Address
                
   (if different from mailing address)       Street Address  
City
  
State
  
ZIP Code
  
Social Security Number/Tax I.D. Number
    
Date of Birth
    
       
(mm/dd/yyyy)
  
   Daytime Phone Number     Home Phone Number    
Email Address      
           
 
3. Provide Contractowner Information
  
o Same as Annuitant
            
Name of Contractowner
 
  
 
      
m Male      m Female
 
First
  
MI
  
Last
    
Mailing Address
                
 
Street Address
  
City
  
State
  
ZIP Code
  
Residential Address
                
   (if different from mailing address)       Street Address  
City
  
State
  
ZIP Code
  
Social Security Number/Tax I.D. Number
    
Date of Birth
    
       
(mm/dd/yyyy)
  
   Daytime Phone Number     Home Phone Number    
Email Address      
           
 
4. Provide Joint Owner Information
  
Name of Joint Owner
 
  
 
      
m Male      m Female
 
First
  
MI
  
Last
    
Mailing Address
                
 
Street Address
  
City
  
State
  
ZIP Code
  
Residential Address
                
   (if different from mailing address)       Street Address  
City
  
State
  
ZIP Code
  
Social Security Number/Tax I.D. Number
    
Date of Birth
    
       
(mm/dd/yyyy)
  
   Daytime Phone Number     Home Phone Number    
           
FSB 237 (08-13)
SecureDesigns 15-90016-08 2015/03/31 (1/5)
 
 
 
 
 
 
 5. Provide Primary and Secondary Beneficiary(ies)
    
 
For additional Primary Beneficiaries, please attach a separate list to the end of this application.
  
   
Primary Beneficiary
    
Social
DOB
Relationship to
%
  
   
Name
Address (city, state, zip)
Phone No.
Security No.
(mm/dd/yyyy)
Owner
of Benefit
  
 
1.
                
 
2.
                
 
3.
                
 
For additional Secondary Beneficiaries, please attach a separate list to the end of this application.
  
   
Secondary Beneficiary
    
Social
DOB
Relationship to
%
  
   
Name
Address (city, state, zip)
Phone No.
Security No.
(mm/dd/yyyy)
Owner
of Benefit
  
 
1.
                
 
2.
                
 
3.
                
   

6. Provide Replacement Information
  
Do you currently have any existing annuity or insurance policies? m Yes m No
Does this proposed contract replace or change any existing annuity or insurance policy? m Yes m No
If yes, please list the following for all life insurance or annuity contracts to be replaced:
         
 
Current Carrier Name
  
Contract/Policy Number
  
 
 
  
 
  
 
 
  
 
  
 
 
  
 
  
 
 
  
 
  
         

7. Choose Optional Riders
  
Please select only one Rider from each category.
Please do not exceed the maximum Rider cost for your contract.
 
Death Benefit Rider Payable Upon Death:
m Annual Stepped Up Death Benefit
 
Credit Enhancement Rider:
m 4%
 
Surrender Charge Riders:
m 0-year Alternate Withdrawal Charge Rider
m 4-year Alternate Withdrawal Charge Rider
 
   
      Please Continue
          
FSB 237 (08-13)
SecureDesigns 15-90016-08 2015/03/31 (2/5)
 
 
 
 
 
    8. Indicate Investment Directions
  
 
Please indicate your investment preferences below. Please use whole percentages totaling 100%
 
 
%
AllianceBernstein VPS Dynamic
 
%
Guggenheim VIF CLS AdvisorOne
 
%
Invesco V.I. Mid Cap Core Equity
     
Asset Allocation
    
Clermont
 
%
Invesco V.I. Mid Cap Growth
 
 
%
AllianceBernstein VPS Small/Mid
 
%
Guggenheim VIF Floating Rate
 
%
Invesco V.I. Value Opportunities
     
Cap Value
    
Strategies
 
%
Ivy Funds VIP Asset Strategy
 
 
%
American Century VP Mid Cap
 
%
Guggenheim VIF Global
 
%
Janus Aspen Enterprise
 
 
  
Value
    
Managed Futures Strategy
 
%
Janus Aspen Janus Portfolio
 
 
%
American Century VP Ultra®
 
%
Guggenheim VIF High Yield
 
%
JPMorgan Insurance Trust Core
 
 
%
American Century VP Value
 
%
Guggenheim VIF Large Cap Value
    
Bond Portfolio
 
 
%
American Funds IS® Asset Allocation
 
%
Guggenheim VIF Long Short Equity
 
%
Lord Abbett Series
 
 
%
American Funds IS® Global Bond
 
%
Guggenheim VIF Macro
    
Bond-Debenture VC
 
 
%
American Funds IS® Global Growth
    
Opportunities
 
%
Lord Abbett Series Developing
 
 
%
American Funds IS® Growth-Income
 
%
Guggenheim VIF Managed
 
 
Growth VC
 
 
%
American Funds IS® International
    
Asset Allocation
 
%
MFS® VIT II Research International
 
 
%
American Funds IS® New World
 
%
Guggenheim VIF Mid Cap Value
 
%
MFS® VIT Total Return
 
 
%
BlackRock Equity Dividend V.I.
 
%
Guggenheim VIF Money Market
 
%
MFS® VIT Utilities
 
 
%
BlackRock Global Allocation V.I.
 
%
Guggenheim VIF Multi-Hedge
 
%
Morgan Stanley UIF Emerging
 
 
%
BlackRock High Yield V.I.
    
Strategies
    
Markets Equity
 
 
%
ClearBridge Variable
 
%
Guggenheim VIF Small Cap Value
 
%
Neuberger Berman AMT
     
Aggressive Growth
 
%
Guggenheim VIF StylePlus
    
Socially Responsive
 
 
%
ClearBridge Variable
    
Large Core
 
%
Oppenheimer Core Bond Fund/VA
     
Small Cap Growth
 
%
Guggenheim VIF StylePlus
 
%
Oppenheimer Global Fund/VA
 
 
%
Dreyfus IP MidCap Stock
    
Large Growth
 
%
Oppenheimer Main Street
 
 
%
Dreyfus IP Small Cap Stock Index
 
%
Guggenheim VIF StylePlus
    
Small Cap Fund®/VA
 
 
%
Dreyfus IP Technology Growth
    
Mid Growth
 
%
PIMCO VIT All Asset
 
 
%
Dreyfus VIF Appreciation
 
%
Guggenheim VIF StylePlus
 
%
PIMCO VIT CommodityRealReturn
 
 
%
Dreyfus VIF International Value
    
Small Growth
    
Strategy
 
 
%
Fidelity® VIP Equity-Income
 
%
Guggenheim VIF Total Return Bond
 
%
PIMCO VIT Emerging Markets Bond
 
 
%
Fidelity® VIP Growth & Income
 
%
Guggenheim VIF World Equity
 
%
PIMCO VIT Foreign Bond
 
 
%
Fidelity® VIP Growth Opportunities
    
Income
    
(U.S. Dollar-Hedged)
 
 
%
Fidelity® VIP High Income
 
%
Ibbotson Aggressive Growth ETF
 
%
PIMCO VIT Low Duration
 
 
%
Fidelity® VIP Overseas
    
Asset Allocation
 
%
PIMCO VIT Real Return
 
 
%
Franklin Founding Funds Allocation
 
%
Ibbotson Balanced ETF Asset
     %
PIMCO VIT Total Return
 
 
  
VIP Fund
    
Allocation
 
%
Putnam VT Small Cap Value
 
 
%
Franklin Income VIP Fund
 
%
Ibbotson Conservative ETF
 
%
Royce Micro-Cap
 
 
%
Franklin Mutual Global Discovery
    
Asset Allocation
 
%
T. Rowe Price Health Sciences
 
 
  
VIP Fund
 
%
Ibbotson Growth ETF Asset
 
%
Templeton Developing Markets
 
 
%
Franklin Small Cap Value VIP Fund
    
Allocation
    
VIP Fund
 
 
%
Franklin Strategic Income VIP Fund
 
%
Ibbotson Income and Growth ETF
 
%
Templeton Global Bond VIP Fund
 
 
%
Guggenheim VIF All Cap Value
    
Asset Allocation
 
%
Transparent Value Directional
 
 
%
Guggenheim VIF Alpha Opportunity
 
%
Invesco V.I. Comstock
    
Allocation VI
 
 
%
Guggenheim VIF CLS AdvisorOne
 
%
Invesco V.I. Equity and Income
 
%
Western Asset Variable Global High
     
Amerigo
 
%
Invesco V.I. Global Health Care
    
Yield Bond
       
 
%
Invesco V.I. Global Real Estate
 Must Total 100%
       
 
%
Invesco V.I. Government Securities
      
       
 
%
Invesco V.I. International Growth
      
                   
FSB 237 (08-13)
SecureDesigns 15-90016-08 2015/03/31 (3/5)

 
 
 
 
9. Salary Reduction Information
  
Please complete this section ONLY if you are contributing through salary reduction.
The Employee’s salary will be reduced by the sum of: $
   or     % per pay period
Beginning:    r Please skip the following month(s):      
  Date (mm/dd/yyyy)      
Will your employer match contributions? m Yes m No
    
Employer Name    
Mailing Address
                
 
Street Address
  
City
  
State
  
ZIP Code
  
Billing Statement Address
               
   (if different from above)           Street Address  
City
  
State
  
ZIP Code
  
   
 
10. Incentives and Other Considerations
  
 
Have you been offered any cash incentive or other consideration (such as free insurance) as an inducement to apply for this annuity contract? m Yes m No
 
To the best of your knowledge and belief, has the annuitant been offered any cash incentive or other consideration (such as free insurance) as an inducement to apply for this annuity contract? m Yes m No

11. Statement of Understanding
  
 
I have been given a current prospectus that describes the Contract for which I am applying. I understand that annuity payments and withdrawal values, if any, when based on the investment experience of the Investment Options are variable and dollar amounts are not guaranteed and that any benefits, values or payments based on performance of the Investment Options may vary and are NOT guaranteed by the U.S. Government or any State Government; and are NOT federally insured by the FDIC, the Federal Reserve Board or any other agency, Federal or State. I further understand that I bear all investment risk except for the amount of funds that are placed in the Fixed Account (subject to availability).
 
If my annuity contract qualifies under Section 403(b), I declare that I know: (1) the limits on withdrawals from my Contract imposed by Section 403(b)(11) of the Internal Revenue Code; and (2) the investment choices available under my employer’s Section 403(b) plan to which I may elect to transfer my account balance. I understand that the amount paid and the application must be acceptable to FSBL under its rules and practices. If they are, the contract applied for will be in effect on the Contract Date. If they are not, FSBL will be liable only for the return of the amount paid.
 
o Check this box to receive a Statement of Additional Information.

12. Provide Signature
  
 
My signature below indicates the information provided within the application is accurate and true, including my tax identification number.
 
Tax Identification Number Certification
 
Instructions: You must cross out item (2) in the below paragraph if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest or dividends on your tax return. For contributions to an individual retirement arrangement (IRA), and generally payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct Tax Identification Number.
 
Under penalties of perjury I certify that (1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and (2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends or the IRS has notified me that I am no longer subject to backup withholding; and (3) I am a U.S. citizen or other U.S. person (as defined in the IRS Form W-9 instructions).
 
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.
           
X          
  Signature of Owner       Date (mm/dd/yyyy)     Signed at (City/State)
           
X          
  Signature of Joint Owner   Date (mm/dd/yyyy)    
FSB 237 (08-13)
SecureDesigns 15-90016-08 2015/03/31 (4/5)
 
 
 
 
 
Registered Representative/Dealer Information
  
 
Will the Annuity being purchased replace any prior insurance or annuities of this or any other Company?
 
o
No, to the best of my knowledge, this application is not involved in the replacement of any life insurance or annuity contract, as defined in applicable Insurance Department Regulations. I have complied with the requirements for disclosure and/or replacement by enclosing a completed and signed Definition of Replacement and leaving a copy of the form with the applicant.
   
o
Yes. If yes, please enclose a completed and signed (i) Disclosure Statement; (ii) Important Notice form; and (iii) Incoming Funds Transfer form. The agent is required to leave with the applicant a copy of the Disclosure Statement and Important Notice form. Also, if an Application Supplement is applicable (for selecting the dollar cost averaging or asset allocation option), please enclose a completed and signed Application Supplement as well.
 
  Comments: 
 
  
   
 
  
  Print Name of Representative     
  X
 
      
   
Signature of Representative
   Date (mm/dd/yyyy)  
Address
                
 
Street Address
  
City
  
State
  
ZIP Code
  
   Daytime Phone Number     Email Address    
           
  Representative Number
 
    
  Print Name of Broker/Dealer
 
    
 
For Registered Representative’s Use Only
    
 
Option: r A r B (default) r C r D
    
 
Important Information About Procedures for Purchasing a Contract
  
 
To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify and record information that identifies each person who purchases a contract.
 
What this means to you: When you purchase a contract, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.
 
Mail to: First Security Benefit Life Insurance and Annuity Company of New York • Administrative Office • PO Box 750497 • Topeka, KS 66675-0497 or Fax to: 1-785-368-1772
Visit us online at www.securitybenefit.com
FSB 237 (08-13)
SecureDesigns 15-90016-08 2015/03/31 (5/5)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
  SecureDesigns 15-90016-08 2015/03/31
   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
  SecureDesigns 15-90016-08 2015/03/31
   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
  SecureDesigns 15-90016-08 2015/03/31